=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417197104
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SECOND CHANCE RECOVERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2009
-----------------------------------------------------
Last Update Date | 02/20/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4012 BENJAMIN CT
-----------------------------------------------------
City | ROCKY MOUNT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27803-1441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-885-4548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4012 BENJAMIN COURT
-----------------------------------------------------
City | ROCKY MOUNT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27803-1441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-885-4548
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | QUALIFIED MENTAL HEALTH/SUBTANCE AB
-----------------------------------------------------
Name | MARION FRAZIER
-----------------------------------------------------
Credential | BA, QMPH
-----------------------------------------------------
Telephone | 252-885-4548
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------